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Does Medicare Cover Substance Abuse Treatment


Medicare can provide coverage for substance abuse treatment. Medicare pays for many substance abuse programs. Including inpatient rehab, outpatient counseling, and medication. Another, more intensive, outpatient option is a Partial Hospitalization Program. To qualify, the doctor must certify that you would otherwise have to be in an inpatient program.

Inpatient Medicare Coverage for Substance Abuse

Part A may cover the cost of the stay for an inpatient facility. Your doctor must write a recommendation for treatment and believe it to be necessary. You must pay Part A deductibles, copayments, or coinsurance amounts that may apply. Also, any inpatient medications for treatment may have coverage by Part A.

Medicare covers the Partial Hospitalization Program (PHP) for substance abuse treatment. Your doctor must certify that you need twenty hours or more of therapeutic services weekly. Then, your doctor must submit a plan for treatment and recertify your needs.

Outpatient Medicare Coverage for Substance Abuse

Outpatient counseling falls under Part B. Counseling for substance abuse, and mental illnesses have coverage. Medicare requires counseling to be in the doctor’s office, a hospital outpatient setting, or a mental health center. Part B covers medicines that are given to you by a doctor, meaning they can’t be self-administered. Part B outpatient drugs that treat substance abuse and addiction have different criteria. Ask your doctor any questions about treatment.

Medicare Advantage Coverage for Substance Abuse

Those with Medicare Advantage coverage have access to substance abuse treatment. But, it’s essential to use an in-network doctor. Otherwise, you pay ALL costs. Some Special Needs Plans help people with specific chronic issues such as mental health or substance abuse. Options for plans vary by county.

Contact your health plan to find an in-network specialist. You can also call an agent at the number above to discuss plan options.

Part D and Substance Abuse Medications

Prescriptions are only covered if you have a separate Part D plan. Part D covers prescription substance abuse medications that you take at home. Each Part D plan has a schedule of covered drugs and their cost. Coverage for a specific medication depends on your policy and whether you use one of the plan’s preferred pharmacies.

Does Medicare cover drug rehab?

Medicare’s substance abuse treatment coverage includes rehab for all types of drug addiction. Coverage extends to those with illegal drug addiction, alcohol addiction, and addiction to prescription drugs.

How long does Medicare pay for rehab?

Part A pays the full cost of 60 days of inpatient rehab in a semi-private room. For days 61 to 90, it costs you $352 coinsurance each day. After the 90th day, the coinsurance amount doubles, and you begin using lifetime reserve days. Medicare only allows 60 of these during your lifetime. If you’ve been an inpatient for over 90 days and you don’t have lifetime reserve days, Medicare won’t pay for care.

A supplement plan can extend the number of days you have hospitalization coverage. If you get inpatient care at a psychiatric hospital, Medicare covers 190 days of lifetime care.

The limit on lifetime days is a problem if you need intensive mental health services or suffer a relapse. But the limitation doesn’t apply to care in a general hospital. For most people in rehab, an inpatient stay is the beginning of the journey. After discharge, Part B will continue to pay for counseling and medical care needed to stay on track.

Does Medicare cover opioid treatment?

An estimated 300,000 Medicare patients had an opioid addiction. Medicare covers treatment for opioid addiction in a hospital or doctor’s office in the same as other treatments. Part B coverage extends to opioid treatment programs and methadone clinics that enroll in Medicare. Coverage includes telehealth services as well as in-person services.

Does Medicare cover Methadone treatment?

Methadone is the oldest and best-known opioid treatment. If administered to an inpatient at a hospital, Part A covers methadone. For people who are not inpatients, methadone is a highly-controlled prescription drug that you can’t get at a regular pharmacy. Patients must go to an opioid treatment center for daily doses of methadone. Medicare covers methadone and other opioid treatment services that enroll in Medicare.

Does Medicare cover substance abuse counseling?

Part A covers substance abuse counseling while you are an inpatient. Part B includes substance abuse counseling when a mental health doctor provides care. Mental health professionals include psychiatrists, psychologists, and licensed clinical social workers. Medicare pays for individual or group sessions. But it doesn’t pay for support groups, peer counseling, or other informal counseling. Medicare will also pay for telehealth counseling as part of an opioid treatment program.

Does Medicare cover addiction treatment?

Overcoming a severe addiction may mean months in inpatient rehab and years of outpatient therapy. Often, people with addictions struggle with mental health issues. Medicare covers addiction treatment, but you may pay deductibles, copays, and coinsurance. Those with a Medigap plan will pay less out of pocket than those with Medicare.

FAQs

Does Medicare Advantage cover methadone?
Yes, Medicare Advantage covers methadone, whether inpatient or outpatient. Advantage plans must offer the same benefits as Medicare. Yet, there is a network of doctors and hospitals. You need to use a facility in your plan’s network to get the most benefit. Also, deductibles and copays vary by policy.
Does Medicare cover suboxone?
Suboxone is a prescription that treats addiction to heroin and prescription opioids. Unlike methadone, you can get Suboxone at a regular pharmacy. Most Part D plans cover Suboxone, but your copay may vary depending on your policy and the pharmacy you use.
Does Medicare Part D cover Methadone 5mg tablets?
Doctors prescribe methadone 5 mg tablets for severe pain. Part D covers methadone for pain, but your copay depends on your plan. Part D doesn’t cover methadone for substance abuse treatment, but Part B might.

How to Get Supplemental Medicare Coverage for Substance Abuse Treatment

Substance abuse treatment can be a long and challenging road, and the costs can add up. A supplement plan can make these costs manageable by picking up cost-sharing. An agent is a professional that can answer your questions and compare all options in your area. Let them find a policy for you; this saves you time and money. Give us a call at the number above or fill out our online rate comparison form for a free quote on policies in your area.

Lindsay Malzone

Lindsay Malzone is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

10 thoughts on “Does Medicare Cover Substance Abuse Treatment

  1. As a hospital based substance use treatment facility, are we able to bill for putpatient substance use services provided by LADC (Licensed Alcohol and Drug Counselor) and/or LMHP (Licensed Mental Health Practitioner)? The hospital is a Medicare provider

    1. Hi Kimberley! Unfortunately, I”m unable to find an answer to your question. I would call Medicare directly to find out the answer. Sorry I couldn’t be more helpful!

  2. Are services provided by an LCAS – Licensed Clinical Addiction Specialist – covered by Medicare? And is there a link available that you could suggest that I could use for reference and print a copy of the policy? Thank you!

    1. Hi Scott! While there is no distinct Medicare benefit category for substance abuse treatment, such services are covered by Medicare when reasonable and necessary. Both inpatient and outpatient treatment would depend on the provider of the services. Coverage and payment would be on a service by service basis for those services that are recognized by Medicare. Some services could be provided by auxiliary personnel incident to a physician’s services. That may be what an LCAS would fall under. CMS has a PDF that you can print a copy of that explains this further in detail. I hope this helps!

  3. We are having trouble with payment for CSAC licensed substance abuse counseling providers. Is this licensure not something Medicare reimburses?

    1. Hi Amber! The work of licensed professional counselors in opioid treatment programs certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) is eligible for Medicare reimbursement, as of Jan. 1, 2020. I hope this helps!

  4. Our mental health/substance use disorder facilty IS credentialed with Medicare, but not as an OTP. We have clients seeking Intensive Outpatient services, however, Medicare does not recognize this HCPCS code or any other that we’re aware. The clients generally have a secondary, but the secondaries will not cover the claims without a Medicare remittance, but Medicare denies our claims electronically because the H0015 is not recognized. I’m at a loss.

  5. Our facility is not certified with Medicare and we have a client that wants to come for Substance Abuse treatment. She also has BCBS as a secondary. Could we as a facility bill Medicare, get the denial and then bill the secondary for payment?

    1. Hi Jacquelyn! Unfortunately, that wouldn’t work since the secondary insurance will only cover the service if Original Medicare covers it. If Medicare denies the claim, so will the supplemental Medicare insurance. I hope this helps!

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